What follows is a series of practical tips that reflect what appeared to us to have affected the outcome of the TCs’ stories. If many seem just common sense, we can only point to the old saying that common sense is not always common. Some points are included because there appeared to be clear benefits when they were well executed, but many are included because the failure to deploy them at one or more sites may well have undermined the intended improvements. These general points highlight some of the important lessons for future organisational innovations in health services, but undoubtedly the most useful lessons will be those that readers will have drawn from relating their own experiences to the TC stories as they read them. It is those varied and specific experiences and contexts that will bring out the relevant lessons for readers’ own organisations.

For policy makers

• 1 Top-down target-led central innovations will inevitably be re-crafted at the local level to suit local needs and build on existing initiatives; they need therefore to retain appropriate flexibility (headroom) if they are to be crafted while still successfully fulfilling their core objectives (see Chapters Two and Three).

• 2 Policy makers should try to facilitate local innovation using not blueprints and design rules but ‘design principles’ that acknowledge the likelihood that rational planning of innovations will be limited in both its feasibility and its applicability in the volatile environment of health service management (see Chapter Seven).

• 3 Even where an organisational innovation has all the attributes of likely success (for example, that it is widely acknowledged to have high relative advantage; seems compatible with the values, norms and perceived needs of those who are expected to adopt it; and has the potential to be adapted to a range of local requirements) there is no guarantee that it will work. It is therefore also necessary to explore very carefully the potential interaction between the innovation, its intended adopters and its context when assessing the likelihood of successful implementation. It is also vital to strive to ensure that related policies do not undermine the intended innovation (see Chapters Four and Five).

Chapter Two highlighted the paradox that, considering all eight sites were part of the same NHS and engaging with the same national innovation programme, their initial circumstances had almost nothing in common with each other. However, they all had local justifications for opening a TC that were the result of complex ‘negotiations’ between different ‘players’ at each site, each of whom interpreted the innovation differently. At each site, key players in the early phases of the development of the TCs contested their understandings and definitions of a TC and what it might mean for the organisation. The tussles, disagreements and bargaining that would shape the resulting TCs were not simple interprofessional (often referred to as “tribal”) battles between, say, doctors, managers and nurses. Rather than splitting along professional lines, they seemed rather to fall into four types of player, namely opportunists, pragmatists, idealists and sceptics, who were to be found in varying proportions in each of the sites. Each type had a role in determining the fate of the innovation, using different aspects of the local initial conditions in each site to argue the case for or against developing a TC (Pope et al, 2006).

Opportunists, pragmatists, idealists and sceptics

Opportunists saw TCs as a chance to do something (rebuild, expand, renew) that they might not otherwise have the chance to do, which was often an innovation they had already been planning or developing. In several of our sites opportunists used the TC programme as a way to get capital funding to finance projects they had long been hoping to implement. At Northendon, for example, a project group had, for a long time, been wanting to expand day surgery in their hospital. Following the announcement of TC funding and prodded by the SHA, the project group developed a bid for a TC mainly as a vehicle for the day surgery unit they had thus far been unable to realise.

The “war on waiting” had been at the core of the NHS policies of the Labour government since 1997 (Harrison and Appleby, 2005) and set the overall policy context for TCs during our period of research. The NHS Plan of 2000 marked a shift away from reducing the number of people waiting and onto the time they waited, by introducing new investments and targets along with a wide range of policies to help transform the way that elective care was provided. The new emphasis was on TCs, day surgery, the NHS Modernisation Agency, specialty programmes such as orthopaedics and ophthalmology (an early focus for TCs) and ‘Patient Choice’. The government also supported the development of new services in community settings; it also set targets for increasing the overall number of hospital beds and introduced a star-rating system for trusts’ overall performance in which five out of nine “key targets” were related to waiting. In 2004 the government announced a new target for the NHS, that by 2008 no one should wait longer than 18 weeks from referral by a GP to hospital treatment. The target was to be helped by extra capacity in the independent sector, which was beginning to become available and was set to increase. By early 2005, the government had agreed to £3 billion worth of contracts with the independent sector to overcome shortfalls in diagnostic capacity alone.

In this chapter we begin by summarising our findings. We than consider some of their implications in terms of organisational theory before, in the final chapter, drawing out some practical conclusions and lessons.

Summary

When The NHS Plan was launched in 2000, TCs were a promising organisational innovation based largely on ideas stemming from a high profile prototype, rather than good research evidence. But their time had come and by 2003, as our study commenced, strong political and organisational forces were spearheading their rapid diffusion in the NHS as an attempt to reduce waiting times and waiting lists for common elective procedures and to foster new forms of patient-centred care. This was all part of a much wider government drive to modernise the organisation and delivery of NHS services, which meant that NHS TCs were launched into the complex milieu of sweeping changes. Some of those changes were always bound to impact on the fledgling TCs (see Chapter Four); they included the encouragement of independent sector TCs, by such measures as the introduction of the ‘G-Supp’ as part of a wider governmental push towards involvement of the private sector; Payment by Results as part of stimulating improvements in organisational performance; and Patient Choice and ‘Choose and Book’ as part of the desire to empower patients. As a result, the story of TCs was not about a single innovation and its impact on services, but about organisational responses to a maelstrom of modernisation. Nevertheless, the dedicated extra funding and the advice from sources such as the Modernisation Agency's ‘learning events’ gave an opportunity for local developments that, although often very different from the Department of Health's ideal, reflected many of its intended principles. The Department might not always have things its own way but the TC programme did stimulate local change that might otherwise not have occurred.

The eight sample sites that we studied differed greatly from each other in their management styles, aspirations and pressures. Their relationships with their external milieu – the host hospital, the PCT, the SHA and neighbouring trusts – and with their own staff also varied from harmonious and constructive partnerships through to downright hostility and conflict.

For all the optimism that surrounded the opening of the eight TCs we were following, by 2006, when our three-year study ended, St Urban’s had closed and Ruckworth was on the verge of doing so (see Table 2.1, Chapter Two). Three of the others (Robbleswade, Stanwick and Northendon) were in deep difficulties due to a paucity of patients and were in discussions about selling space and/or capacity to the independent sector. (Since then, however, they have resolved their problems in their different ways and are still, in 2010, operating as NHS TCs.) Only three of the eight were functioning in 2006 comfortably within the NHS as part of the NHS TC programme. Two of these, Pollhaven and Lakenfield, were relatively small-scale initiatives that had been absorbed back into their host trusts, but were still attempting, with differing levels of success, to practise the ideals of re-engineered care pathways that separated elective and emergency care, increased activity and improved patient experience. Only one of the eight, Brindlesham, appeared in 2006 to have weathered the storm to emerge as a standalone unit that largely mimicked the early ACAD and exemplified key elements of the original policy model of what an NHS TC should be.

What were the reasons for the ways the TCs turned out at the end of our study? To a large extent the answer lay in the available capacity of the hospitals in a TC's catchment relative to the total number of patients. At one extreme, Ruckworth, Stanwick and St Urban's were opened in an environment where there were simply not enough patients to allow them to compete effectively in an era of Patient Choice, ‘G-Supp’ or independent sector TCs (see Chapter Four), and the effects were devastating. Lakenfield, at the other end of the spectrum, had a shortage of beds and therefore faced little threat from such policy shifts. At the other four TCs it took a great deal of wheeling and dealing, competitive marketing and collaboration with the commissioners and providers of healthcare to achieve a reasonable throughput of patients because the original planning assumptions had proven to be over-optimistic. The immediate question, therefore, is why the predictions of patient numbers had proven so unreliable.

Whatever the eventual problems, all of the TCs in our sample had, more or less explicitly, a group of enthusiasts, mainly the ‘idealists’ (see Chapter Three), who generated the momentum and the energy to try to bring about innovations and improvements in care in the TCs. For them, the tumult of national policy changes and failing local business models was background noise as they strove to introduce practice innovations for their own TC, invariably meeting local resistance from one source or another even when other sites might regard the change as unexceptionable. This chapter examines those innovations in care, including changes in both the structure, such as transformations in the physical environment and in staffing, and the process of care, such as the application of new clinical pathways.

Achieving targets: structure, process and outcome?

Despite the mixed motives for the innovation and all the difficulties that emerged once they were running, most of our case study TCs increased the throughput of patients and all were thought by the wider health economy to be important contributors to achieving not only waiting list targets, but also providing greater patient choice. For example, Ruckworth, for all its difficulties, was nevertheless helping its partner trusts to meet the government's stringent waiting list targets. As our fieldwork was ending, an option appraisal there, which included the suggestion that the unit be closed down, concluded that the TC should be kept open, and a number of suggestions were made to help limit (and share) the continuing financial losses. This was based on the view that over the coming two or three years there would still be a need for at least some of the beds to remain open in order to continue to meet those targets. Even St Urban’s, which was eventually forced to close, was able to capitalise on its unused facilities to make a significant contribution to meeting its host hospital's waiting list targets. Ironically this was not due to its different ways of working; the average length of stay of patients going through the TC was no different from the rest of the hospital.

Sampling and site access

We used a multi-method case study design (Eisenhardt, 1989; Yin, 1994, 2003). We selected eight case study sites, using the preliminary information that we had gathered in preparation for the proposal. The selection of sites was also informed by meetings with the director and members of the NHS Modernisation Agency team responsible for the treatment centre (TC) programme. The sampling was intended to ensure that the case study sites provided a broad representation of the range of TCs either existing or in development as at March 2003 when the research began.

The selection characteristics that we considered were:

• • geographical (for example, urban/rural);

• • type of host trust;

• • organisational (for example, integral or separate from host trust; NHS ‘star rating’ of host trust; likelihood of foundation hospital status);

• • intended case mix (such as single or multiple specialty, routine or more complex cases);

• • the stage of development (from those that were already open, through to those in the early planning stage);

• • scale (as measured in terms of planned numbers of patients);

• • new/purpose-built or not;

• • degree of private sector involvement;

• • commissioning model (such as whether reliant on multiple or single commissioners).

Ethical approval for the study was sought from a Multi-centre Research Ethics Committee in January 2003, and full approval was granted on 14 April 2003 (MREC/03/07). Management approval for the study from the relevant NHS trust chief executive or TC director in each of the sites was then obtained.

All but one of our original choices agreed to be case study sites (see Table A2.1). The sites were given an information sheet about the study. When they had accepted, a local ‘site representative’ was appointed from among the senior staff associated with the TC. With the help of this person, key initial informants in each site were selected for interview, based on their roles and involvement with the TC.

The sites selected ranged from relatively small initiatives (a single ward, Phase I of Lakenfield) to much larger enterprises including centres that operated essentially as a mini-hospital (Ruckworth and Robbleswade). Some were new purpose-built facilities (Robbleswade, Stanwick, Northendon, Pollhaven and Phase II of Lakenfield), some were refurbishments of facilities within the host organisation – usually a hospital (Brindlesham and St Urban’s) – and one (Ruckworth) was a separate leased building.

Treatment centres (TCs) were intended to deliver high volumes of high quality care using modern, efficient methods based on well-designed care-pathways. The key was separating elective from emergency care so that TCs could concentrate on delivering booked services according to planned protocols with the additional benefit of routinely offering patients choice and convenience. To achieve these aims, there was a guiding expectation that novel patient pathways would be planned that did not necessarily treat conventional departmental or professional boundaries as sacrosanct. The new model of care was expected to be innovative in focusing on the needs of patients rather than of the organisation and, where possible, providing a one-stop shop where the provision of diagnostic and treatment services improved both the efficiency of the service and the experience of the patient.

These defining characteristics of TCs were frequently reiterated in Department of Health and NHS material. Such sources also frequently repeated the point that there was no single model for a TC, whether run by the NHS or the private sector. Rather than a single model for all circumstances, TCs could be anywhere on a continuum from relatively simple primary care-based developments through traditional day case units to full blown elective ‘factories’ For example:

The NHS archetype of treatment centres

The concept of the treatment centre (TC) had roots that existed well before the 2000 NHS Plan that promulgated the scheme. The model of ambulatory surgical centres and other forms of ‘focused factories’ (Casalino and Robinson, 2003; Casalino et al, 2004), which had existed in US healthcare since the 1970s, had meant that neither the archetype nor its context was wholly new to the NHS. Indeed five planned ambulatory care centres in England, two of which subsequently became part of the TC programme, were discussed in a report in the mid-1990s (NHS Estates, 1996, p 4). But it was the Ambulatory Care and Diagnostic Centre (ACAD) opened at the Central Middlesex Hospital in North West London in 1999 that was most cited as the prototype for the TC programme.

The ACAD is a purpose-built two-storey free-standing unit on the site of, but administratively distinct from, its host hospital. The building itself won high praise and awards from architects and others involved with healthcare construction and facilities provision, which probably contributed to the ACAD's high profile in the NHS. However, the ACAD's main claim to fame was the process by which it managed a wide range of elective day case work with in-patient stays that exceeded one day in only five per cent of patients. Its distinguishing features relative to conventional day case units were the ‘strong emphasis on protocol-driven care’ and the significant role played by the ‘scheduler’ in the organisation (Bowers et al, 2002, p 306).

Variation from beginning to end

Considering that this was supposed to be a unified national initiative, it was astonishing just how varied the eight case study sites turned out to be, not only in the manner in which the innovation occurred, but also in the configurations of the TCs themselves. Looking back, it should have been obvious that they would come in all shapes and sizes. After all, every previous central innovation of this kind, such as day surgery units in the 1980s or NHS Walk-in Centres in the 1990s, had spawned a mass of varied models. Indeed the Modernisation Agency had made clear that TCs should vary depending on local circumstances. But what they had in mind was the rational redesign of the same basic principles according to the likely demand for particular surgical services in localities with dissimilar populations. In fact the huge variety that emerged depended more on the happenstance of local organisational culture, politics, finances, relationships and buildings than on any rational analysis of local healthcare needs.

In order to understand this variety, and also to lay the foundations for understanding just what it was that shaped the innovation and its varied fate over time in different localities (see Table 2.1), we start by reviewing the initial conditions at each site. What kind of organisations were these NHS trusts that decided to become part of the early TC movement? How and why were they in a position to do so? We look here at each site in turn, examining both the internal circumstances and the external environment of each. Then, in the following chapter, where we examine their motives for opening a TC, we will be in a position to see not only how widely and why those reasons varied from place to place but also how wide-ranging they were in any particular hospital. Yet – as we shall see – despite this variety, there were also common features across the eight sites that will help us to understand how and why such an innovation evolves.

Learning from case studies of an NHS innovation

When the UK government announced in 2000 that over 40 major diagnosis and treatment centres (DTCs) would be introduced across the National Health Service (NHS), the idea was generally acclaimed as one whose time had come. DTCs were an innovative way of providing healthcare to thousands of patients with specific healthcare needs (see Appendix 1). Mostly purpose-built, DTCs would be designed to ensure that elective patients requiring straightforward diagnosis or treatment would avoid long waits and unnecessary hospital stays. DTCs would, moreover, spearhead the modernisation of ways of working in the NHS, another equally important priority that included the redefinition of professional roles and the spread of pre-defined pathways of patient care. Hospitals throughout the NHS rushed to get involved. Within a year of the original announcement, eight DTCs were already up and running, and by the end of 2006 there were 46 in place, with many more being planned. Yet, as with so many healthcare innovations, these DTCs or treatment centres (TCs), as they were later relabelled, did not turn out quite as central government had originally envisaged.

Although TCs are now an established part of the NHS, the lessons that we learned from studying their introduction remain poignantly relevant, since similar large-scale initiatives in the organisation and delivery of healthcare are – and are always likely to be – a continuing feature of central government policy making. There are many important questions one could ask specifically about TCs, such as whether the policy to establish them has been successful, how the new arrangements have affected patient experience and outcomes, whether professional roles changed for the better, what works or does not work in the management of elective patients and whether private sector involvement has improved the service. This book, however, focuses on a broader question – how local managers implement an innovation driven by national policy. That generic question will always retain far-reaching relevance since the tension between centrally driven, top-down policy and the local management of change is a permanent part not just of the NHS but any large healthcare system – indeed of any large public sector service in any country. And it is nearly always problematic.